Chapter XXXIV: Fractures (2)

=Symptoms.=--These are often vague, when but a single rib has been cracked through and not displaced, and comprise pain on pressure, as well as that provoked by deep breathing, coughing, and certain other movements. Should this pain be limited, or constant and made worse by pressure, fracture of the rib may be suspected. If auscultation crepitus can be heard, diagnosis is at once made. When abnormal mobility is unmistakable, or when by any means crepitus is elicited, the signs are positive. Sometimes the patient himself will recognize crepitus. This may be learned either by auscultation or by pressure with the flat hand over the affected area. _Emphysema_ is an unmistakable evidence of fracture with perforation, while the signs of the presence of fluid in the chest cavity will also indicate fracture.

=Treatment.=--Fracture of one or two ribs with displacement is ordinarily a matter of trivial import, the adjoining ribs acting as splints. It necessitates practically nothing but physiological rest, which may be best afforded by keeping the patient in bed, with _firm compression_ around the chest, made either with a binder of strong cloth or a broad piece of adhesive plaster carried nearly around the body, or in more aggravated cases by a plaster-of-Paris jacket. In thin individuals the formation of callus can be recognized by the sense of touch. So soon as this is fairly formed displacement is less likely to occur and uncomfortable compression may be relaxed. Should there be external angular displacement this may be corrected by pressure. A projecting fragment which threatens to perforate should be cut away with bone forceps through a small incision, taking pains to permit as little air as possible to enter. If there be a _traumatic pneumothorax_ the air should be removed with an aspirating needle. When it is evident that there is serious injury to the chest wall and that air has already separated the lung from it (traumatic atelectasis) the parts should be freely exposed, to permit the rounding off of bone ends, the seizure of intercostal vessels, the cleansing out of the pleural cavity, with perhaps later wiring of fragments or else their complete removal and closure of the external wound with or without drainage, as may be required. If blood or air has already escaped into the pleural cavity the blood should be speedily removed. The same plan is advisable in fractures of the cartilages. Sedatives to check cough, _e. g._, heroine, are also indicated.

FRACTURES OF THE CLAVICLE.

The clavicle and the radius are the two bones most frequently broken, the former more often in the young, the latter in the elderly; the clavicle yields both to direct violence, as by blows on the shoulder, and that which is transmitted through the arm from the elbow or hand. For convenience of description the bone is divided into thirds, the most common location for fracture being near the junction of the middle and outer third. Save for epiphyseal separations the extremities of the bone are seldom broken. In spite of its subcutaneous position and its proximity to large vessels, compound injuries or other complications are quite uncommon.

The clavicle is the brace which keeps the shoulder proper from falling upon and around the thorax. _Consequently when it is broken the shoulder tends to drop downward, forward, and inward_, except in a green-stick fracture, while even then there may be some displacement in these directions. Deformity is usually easily recognized, one or other fragment projecting beneath the skin in such a way as to be easily palpated. There is enough spasm of cervical muscles to draw the head over toward the affected side, while there is loss of function in the affected arm. Pain is made worse by pressing the shoulder inward as well as by moving it in any direction.

In young children the bone is often broken with a minimum of displacement. Fracture of both clavicles is not so very rare. Trouble may occur later in the course of the case from pressure of exuberant callus upon nerves and even vessels. This is to be prevented by foresight and by careful attention to maintenance of parts in proper position.

=Treatment.=--The multiplicity of dressings which have been suggested for fractures of the clavicle attest the fact that so long as primary indications are observed the treatment can be made very simple. These indications are to _keep the shoulder upward, outward, and backward_, as it tends to drop in the opposite way. The action of three muscles is of great importance in considering the proper treatment of these cases, _i. e._, the sternomastoid and the trapezius, because they tend to pull fragments upward, and the pectoralis major because advantage can be taken of its arrangement to overcome upward displacement. It was Moore, of Rochester, who taught many years in Buffalo, who showed how this could be done. The fibers of the great pectoral which arise highest, _i. e._, from the clavicle, are those which are inserted lowest along the bicipital groove of the humerus, because of the semi-revolution made by the tendon of this muscle as it passes to its insertion. By putting the arm in such a position that these fibers are pulled upon the operator may counteract the upward pull of the other muscles just mentioned. This is the underlying feature of Moore’s suggestion; to force the elbow far backward, into a position which is for the time being uncomfortable, in order thus to pull down fragments which jut up beneath the skin. Any dressing which permits this position to be maintained will be equally serviceable. Moore suggests for this purpose what he calls a double figure-of-eight, which is shown in Figs. 284 and 285. It is put on as follows: A strip of cloth, sheeting, or anything of the kind, about two yards in length and folded sufficiently to make a strong strip eight inches wide, is held near its middle over the surgeon’s hand. This hand is placed beneath the elbow of the injured side, so that the strip crosses the under surface of the flexed forearm at the elbow. One end, which should be the longer, lying to the inner side, is passed upward and in front of the arm, carried over the shoulder across the back and under the opposite axilla, then over in front of the sound shoulder, meeting on the back the other end, which is carried up first over the outside of the forearm, then behind the shoulder and across the spine. This bandage should be pulled tightly, while an assistant holds the elbow as far backward and upward as the patient can tolerate it, as the more the position is exaggerated the more are the clavicular fibers of the muscle pulled upon and the better are the fragments held in place. This dressing not only meets the three primary indications laid down, but gives the added advantage just described. By it the shoulders are drawn backward and fixed to each other. The _elbow should be lifted_ as the dressing is applied, so as to lift the shoulder. Most of the cloth materials used for such a dressing are more or less elastic, and it may need to be tightened once or twice a day during the time that it is worn. After a few days, when consolidation should have occurred, it may be changed for some other less irksome form of dressing. The hand should be supported in a sling. This dressing is useful in dislocations of the clavicle, especially of its outer end, and in every kind of injury in which the indication is to hold the shoulder upward and backward. In simple cases without much displacement the primary indications may be more simply met by a dressing of adhesive plaster, known in the East as Sayre’s and in the West as Freer’s. It consists of two strips of plaster of about the width of the arm itself. One of them is wound around the upper end of the arm, close to the shoulder, in such a way that, as it is passed around the back and brought over the chest, the arm and shoulder are pulled backward. The other strip passes from beneath the elbow of the injured side obliquely up and over the opposite shoulder. When it is applied the elbow should be _firmly lifted_. After the completion of either of these dressings the injured shoulder should appear at least one inch higher than the well one. Should the patient’s arm and chest be hairy they should be shaved before the application of the plaster strips. Like other material, plaster will stretch and slip, and these, like other dressings, should be readjusted every day or two, _for the shoulder should be kept elevated for at least a week_.

Moore’s apparatus (back view).]

Moore’s apparatus (front view).]

When the case is complicated by other injuries necessitating confinement in bed it is sufficient to keep the patient flat upon the back and without a pillow. In this position the shoulder falls naturally in the direction desired, and perhaps no other attention will be required. Many other methods are combined with a figure-of-eight bandage, crossing the back and forming a loop over each shoulder, so as to keep it from dropping forward.

While the results of treatment are nearly always good, if one is insistent upon a minimum of deformity, confinement upon the back on a hard bed is the surest way to obtain satisfactory results. Cases in which there is little or no tendency to deformity need only the simplest support by which rest may be ensured.

Epiphyseal separations are to be treated as fractures.

FRACTURES OF THE SCAPULA.

The most frequent fracture of the scapula is that of the _acromion_; this is usually the result of direct violence, such as a fall upon the tip of the shoulder. Detachment of this fragment permits a peculiar flattening of the shoulder, but without dislocation. The fragment can be easily felt, while the deltoid is displaced and its rounded contour lost. Treatment consists solely in _forcing the arm upward_, by dressings applied beneath the elbow, thus lifting the fragment into its place; fibrous union occurring here much more often than osseous, the latter is possible only in case a good apposition be maintained. Any form of dressing, then, by which the elbow is crowded upward and rest maintained will be appropriate.

The _surgical neck_ is occasionally detached, sometimes with and sometimes without the coracoid process. As the humerus is attached to it by the capsular ligament the arm drops with the fragment when the patient is in the upright position, and the elbow will be found lower than that of the injured side. The arm is unduly mobile, and the fragment can usually be seized and crepitus obtained within the axilla. Here it is necessary to hold the arm up, as it controls the position of the fragment. It is usually sufficient to lift the elbow up and bind the arm firmly to the side, the scapula being immobilized by broad straps of adhesive plaster.

The _coracoid process_ is occasionally detached, usually by muscular violence, _i. e._, it is pulled off by the coracobrachialis and the coracoid head of the biceps which arise from it. The injury is recognized by failure to detect the process in its proper place, and usually by discovery of the fragment at a point below its normal position, to which it has been drawn out by the muscles arising from it. Ligamentous union can be secured by relaxing these muscles, which is done by placing the hand over the opposite shoulder and dressing the arm firmly against the chest. I have seen paralysis of the arm result from excessive callus after fracture of the coracoid.

The _spine_, _body_, and the _angles_ of the scapula are occasionally broken by severe violence. In the aged comminution may occur. Crepitus can be nearly always obtained. It may be necessary to distinguish the scapular fracture from one of the ribs beneath it. The treatment consists in simply fixing the shoulder-blade upon the chest, to which it is naturally adapted, by firm bandages, which shall immobilize not only it but the arm as well.

FRACTURES OF THE HUMERUS.

At the _upper end_ of the humerus we deal with fracture of the processes, _i. e._, the _tuberosities_, which may be torn off by violent action of the muscles therein inserted; of the _anatomical neck_, which is rare and occurs most often in the aged; of the _surgical neck_, which is the most common; or, in the young, _epiphyseal separation_, which is the equivalent of the last named. Separation of the tuberosities is diagnosticated mainly by exclusion, possibly by _x_-rays. The _anatomical neck_ lies within the capsule, and should the head be thus detached it might remain as a foreign body in the joint, having no means of securing nutrition. Fractures of the _head of the bone_ are not classical and are usually the result of gunshot injuries or extreme violence. In all of these injuries there will be swelling, loss of function, while crepitus is sometimes obtained, but is very difficult to locate, even under an anesthetic. The diagnosis is to be made mostly by exclusion.

The _surgical neck_ is the most frequently broken; the line of fracture passing below the tuberosities and above the muscles inserted along the bicipital groove. Therefore the pectoralis and the latissimus muscles will both conspire to pull the upper end of the shaft toward the thorax to such an extent that it can be felt in the axilla. This gives its axis a different direction, while all the muscles extending from the shoulder to the forearm will tend to produce shortening. Deformity is usually distinct, crepitus is easily obtained, and undue mobility is well marked. The head of the bone can be detected in its proper place beneath the deltoid, but does not rotate with the shaft. In rare instances a certain amount of impaction may make this evidence of fracture obscure. _Epiphyseal separation_ will give the same signs and symptoms.

=Treatment.=--The primary indication here is to overcome muscle pull by traction in a direction toward the crest of the pelvis of the same side. At the same time, with a certain degree of coaxing of the upper end of the shaft outward and a little forward, it may be possible to so re-apply broken surfaces to each other, and so affix the arm to the thorax, as to be effective. When serious difficulty, however, is encountered the writer advises traction, applied to the arm alone, if the patient be able to be upright, or to the arm and forearm, if he be confined in bed. It will take considerable stretching to overcome the combined action of all the muscles which tend to produce displacement. Along with such treatment a coaptation splint should be applied, the best being that which can be carefully molded to the parts and adapted to their needs. For this purpose a molded plaster-of-Paris splint is preferable to one of metal made to some standard size. In the dressing it is necessary to include not only the shoulder and arm but also the forearm, otherwise the principle of physiological rest would not be enforced. Fig. 286 illustrates the common tendency to displacement in these injuries.

_Fracture_ of the surgical neck is occasionally combined with _dislocation_ of the head of the humerus, by which such an injury is seriously complicated. Reduction may be attempted by manipulation. Until recently it was generally advised to wait for a week or ten days, and until consolidation had occurred, and then to make the attempt at reduction; but Porter and McBurney have shown that it is advisable to cut down upon the dislocated upper fragment, and, fixing it with forceps or with an instrument shaped like a corkscrew or hook, to force it back into place again. If this be done under the strictest precautions it lends no serious features to the case, while, in most respects, such a procedure would greatly simplify it, the wound being closed with or without drainage, and the usual fracture dressing being applied.

In cases of _old fracture and dislocation_ the head of the bone should be exsected, the functional result thus obtained being excellent.

_Epiphyseal separation has been too often mistaken for dislocation._ Fig. 287, from Moore, shows how the periosteum is not necessarily entirely detached, but is stripped up to form a hinge, the fragment displaced forward, and its outer aspect often turned upward. This makes traction in an outward direction an essential feature of the replacement of the fractured surfaces, the manipulation being combined with fixation of the fragment so far as it can be seized through the axilla. If the epiphysis is properly slipped over upon the end of the humerus the case assumes ordinary features, and is to be dressed as usual.

Fracture of the surgical neck of humerus. (Hoffa.)]

Separation of the upper epiphysis of the humerus; displacement forward of the lower fragment. (Moore.)]

The shaft of the bone is frequently broken, lines of fracture running in all directions and occurring at all levels. A variety of displacement may take place. The evidences of fracture are usually recognizable and diagnosis is not difficult. The brachial artery and the musculospiral nerve are occasionally involved, either in callus or by primary injury from a spicule of bone. These fractures are more liable to delay in union or even to non-union than almost any others. These occur often without evident cause, while more or less absorption of bone has been known, by which complications are produced.

In the _treatment of fractures of the shaft_ posture is necessary to observe, the fragments not only being held in position, but the axis of the bone being maintained. An external splint, extending up to and rounded over the shoulder, and an internal splint molded to the inner side of the arm, taking in the elbow and forearm, and placed at a right angle, and then the immobilization of the entire arm by its fixation to the body will give the best result. The writer prefers to make these of plaster of Paris, by molding strips of surgeons’ lint sopped in plaster cream, and maintaining the limb in the desired position while they harden. Should comminution be extreme, or shortening difficult to overcome, a few days’ confinement in bed, with traction upon the forearm, either extended or included in the above dressing, by the usual method, with weight and pulley, will give the best result. So soon as callus has bound the ends of the bone together the patient may be released from bed and the arm left in the right-angle position, in plaster, as above. Or over such a splint as has been described, made of molded plaster, may be hung by a bandage at the elbow sufficient weight (a bag containing shot) to maintain constant traction upon the lower fragment, while the patient is in the upright position, and to influence for good any overlapping or displacement of any kind during the critical period when the bone ends are being united by callus.

The _epicondyles_ are occasionally chipped off from the condyles, the internal being the more frequently injured. These detachments are extra-articular and are relatively unimportant, the fragments being kept from displacement by their fibrous investments. If such an injury should be compound any fragment completely loosened should be removed. It is sufficient to dress such an injured elbow with cold wet compresses in the flexed position. _Supracondyloid_ fracture, or its equivalent in the young (an _epiphyseal separation_) are somewhat similar, the latter occurring nearer to the articulation than the former. In each of these injuries the arm is flexed and shortened, the fragment lying usually in front of the shaft and the olecranon protruding posteriorly. The more the arm is extended the more prominent the deformity, while by flexion it is much diminished. Hence the advantage of dressing it in the position of overflexion sometimes called Jones’ position.[39] Injury to the vessels at the bend of the elbow may occur in these fractures. If not dressed in this position the elbow should be put at a right angle, while a weight is slung over the elbow, as already mentioned above. Joint function will be greatly hampered if complete extension and reduction be not effected (Fig. 288).

[39] In supracondyloid fractures there is almost always posterior and
upper displacement of the lower fragment. When the parts are found
in this position, and especially when the skiagram shows the line of
fracture in the usual location (from above downward and forward), the
fracture should be treated by flexion of the arm in the so-called
Jones’ position. By this the fragment is best restored to its proper
position, being pried there by the muscular cushions of the forearm
and arm. (Ashhurst.)

Supracondyloid fracture or epiphyseal separation. (Lejars.)]

In considering fractures about the elbow no greater aid can be obtained than by a study of the relations of the three prominent or salient anatomical points to each other. These are the internal and external condyles and the tip of the olecranon. They afford a key to nearly all the displacements which may be produced after fracture or even dislocation, and the only conditions under which they cannot be made available are those where there has been tremendous swelling before the case is seen by the surgeon. A fourth prominent feature, the head of the radius, is also of much assistance, but is less often available, especially in muscular or swollen forearms. When a normal arm is flexed to a right angle and viewed from behind the three points above mentioned constitute the angles of a nearly equilateral triangle. When seen from the side the point of the olecranon is just below the external condyle and in the same plane; when the arm is completely extended and viewed from behind these three points are practically in the same line. By a careful study of the variations from the above relations which are produced by injury diagnosis can be greatly facilitated.

T-fracture of humerus. (Helferich.)]

T-shaped fracture of lower epiphysis of humerus.]

Intracondyloid fracture of humerus. Almost perfect functional result. (Parmenter.)]

Gunstock deformity after fracture of internal condyle, illustrating neglect of precautions mentioned in text. (Beatson.)]

The _condyles_ may each be broken loose by itself, or they may be _both broken_ at the same time. Fig. 291 illustrates what is known sometimes as a T-fracture, where the lower extremity is not only separated from the shaft but is broken into halves; such fractures imply great violence, and are particularly difficult to treat. Should the condyles be detached in such a way as to leave the lower end of the humerus in pointed wedge shape it may perforate or do much harm to the soft parts (Fig. 290). In these _intercondyloid_ fractures the writer would advise dressing in the extended position, with a molded plaster-of-Paris anterior splint and a gentle degree of traction, the patient being confined to bed for a few days. In applying such a splint the surgeon should give extreme care to holding the fragments in proper position while the splint hardens, and in preserving the “carrying function” (Fig. 291). (See below.)

Supracondyloid Fracture. (Child, nine years old.) Union with deformity, fragment so joined to lower end of shaft of humerus at an angle that when forearm is completely flexed upon this fragment it yet is only at right angle with the arm. Operation indicated. (X-ray picture.)]

The _external condyle_ when fractured is displaced by muscle pull; when the _internal condyle_ is broken the tendency is to backward displacement of the fragment and widening of the joint.

_Fracture of the internal condyle_ is often an exceedingly serious matter, because it is so often associated with more or less dislocation and with permanent deformity, as a result of inattention to the anatomical relations of the bones. The ulna sustains peculiar relations to the inner condyle; at its upper end it is wrapped around the process, holding it much as a monkey-wrench can be made to seize an ordinary object, and being held to it by the internal lateral ligament. Herein lies the secret of success or failure in treatment, for the fragment, being so fixed to the ulna, should be controlled by it, _i. e._, the position of the ulna is the most essential feature of the treatment of the fracture. The forearm makes an angle with the arm proper, by which a considerable degree of divergence is maintained. This has been alluded to by Allis and others as the “carrying function.” It can _only be estimated in the extended position, and be accurately judged by comparison with the other arm._ If the arm be flexed all possibility of estimating it is lost; therefore to _dress such a fracture in the right-angle position is bad practice_ (Fig. 292). The only position in which the carrying function can be preserved is the extended, or one a little short of it for the purpose of comfort. If the ulna is put in the proper position the fragment will be held equally so or as nearly as possible (Fig. 294).

Fracture of external condyle. (Lejars.)]

In the _treatment of fractures of the inner condyle_ the patient, if a child, should be anesthetized, the upper part of the body exposed, both arms extended, and the injured arm made to correspond exactly with the other so far as concerns the angle of divergence. Upon the arm so placed an anterior plaster-of-Paris molded splint should be carefully applied, extending from axilla to wrist, and then lightly secured with bandages, the surgeon holding the arm in the proper position _until the plaster is sufficiently hardened to permit no displacement._ The arm should be kept in this position for at least ten days, after which the splint may be removed and gentle motion practised. It may then be reapplied for two or three days, after which we may begin to flex the arm, applying either a new plaster splint or any other that seems suitable, and in such a way that at the expiration of another week the forearm is brought to a comfortable position of right angle, where it may be maintained with a light splint or simply with a sling, according to the age and tractability of the patient. Fig. 294 illustrates the splint and the position, which is the only one in which the surgeon maintains his own security and can properly estimate the carrying function. The mistake has been in dressing this fracture, like most others at the elbow, in the right-angle position.

In _fractures of the outer condyle_ these anatomical conditions do not prevail, and these may be dressed in whatever position best meets the indications of comfort and accurate reduction. _Intercondyloid fractures_ are subject to the same conditions as those of the _internal condyle_, plus others which are added, and should therefore be dressed in the _same position_.

Molded plaster splint for entire arm, and especially for fractures of the internal condyle, showing proper position for dressing same.]

_Epiphyseal separations_, as well as supracondyloid fractures, should be dressed either with traction in a somewhat extended position, or in that of extreme flexion, called also Jones’ position, according as the fragments may best fall into place in one or the other.

Molded plaster splint for arm.]

Molded plaster splint for forearm.]

The writer has for his own purposes discarded almost all other splint material for the upper extremity in favor of the plaster-of-Paris splints already mentioned. Figs. 294, 295 and 296, may illustrate the method and purpose of their use; many other modifications can be devised as may be demanded. It is customary, after such a splint is hard and firm, to remove it for a few moments, trim it, smooth the edges, line it with a fresh piece of soft lint or its equivalent, and then reapply it to the arm with a roller or starch bandage, the arm meantime not having been disturbed, but maintained in its proper position, and being restored to the splint and made to take its previous position. Such a splint fits accurately the individual for whom it is made. It is worthless for anyone else; nor should it ever be used again, the _intent being to mold a splint for each case which shall serve its individual purpose and none other_.

Too early passive motion with the intent to regain mobility is inadvisable and often dangerous. A fractured joint should be kept at rest until the bone is consolidated. If callus be thus reduced to the minimum, and consolidation be undisturbed, the patient will, in due time, recover motion, often to the extreme limit. In fractures of the humerus five or six weeks are required for the attainment of perfect union. In spite of precaution callus formation will sometimes be excessive and interfere with motion. Absorption of exuberant material then is most desirable. This can be encouraged by constant but gentle pressure. Thus when callus in front of the lower articular surface of the humerus obstructs the coronoid process of the ulna and prevents complete flexion the patient should wear for several hours at a time an elastic sling, made with a piece of Martin rubber bandage sufficiently long to make a loop around the neck, into which the hand is passed. It should be made so tight as to exert gentle but constant pressure; the result of this will be to cause rapid disappearance of the callus upon which it is made. Conditions may be reversed when necessary, and the patient may have some weight affixed to the hand by which, when the arm hangs down, reversed pressure shall be made, or when desirable these measures may be alternated. One should not, however, be tempted into resorting to them too early, since much is done, even in unfavorable cases, by purely natural processes, this being especially true of children who are growing rapidly.

FRACTURES OF THE FOREARM; THE ULNA.

At the upper end of the _ulna_ the most frequent fracture is that of the _olecranon_, whose separation by direct or indirect violence corresponds to fracture of the patella. The fragment is pulled upward along the back of the arm by the triceps muscle, and the power of extension is almost lost. There is rarely any difficulty in diagnosis, except in conditions of extreme swelling, which of itself would be suspicious, as under hardly any other circumstances could a joint be so distended (Figs. 297 and 298).

Fracture of olecranon. (Erichsen.)]

Fracture of ulna, upper end. (Lejars.)]

Fracture of olecranon with fibrous union. (Park.)]

=Treatment.=--The difficulty here, in _treatment_, consists in the necessity for counteracting the pull of the triceps. The arm first of all should be dressed in the _extended position_. Sometimes it is possible, by partly encircling the posterior surface of the arm just above the fragment with a strong piece of adhesive plaster, to which is attached some rubber tubing, to make a constant elastic pull upon the fragment, the tubes being brought down and attached to the sides of the anterior splint below the elbow. In the absence of swelling this can often be made quite effective. So long as much fluid is present no means will be efficient. It may, therefore, be well to wait two or three days until the fluid has disappeared, aspirating the joint if necessary. In young and otherwise healthy subjects there is strong reason for advising _operation_, as only by absolutely approximating the fragment to the main bone and maintaining it in position can bony union be secured. In properly selected cases, and when performed with every precaution, this measure frequently gives ideal results. A short ligamentous union is represented in Fig. 299. At other times the fibrous band will stretch out to an inch or more, not completely disabling the arm but weakening it. The extended position may be relaxed within a week after operation, but not for at least two weeks after other treatment. Passive motion should not be begun too early in the latter cases.

Fracture of the _coracoid process_ is often combined with _backward dislocation of the forearm_, which is no doubt an incident of the injury or may occur later by mere muscle pull. The brachialis anticus, which is inserted into it, will pull the fragment up against the anterior surface of the humerus. This fracture should be dressed in the right-angle position, in order to relax the muscle, taking care to prevent backward displacement, while ligamentous union is ordinarily all that can be hoped for.

The _ulnar shaft_ may be broken at almost any point, usually as a result of direct violence. As it is weaker in its lower half the greater number of fractures occur here. Fracture of the shaft is easily recognized, crepitus being always obtained, unless muscle tissue has intervened, this being a condition which will occasionally prevent bony union. If it can be established by _x_-rays that bony surfaces are not in contact and cannot be so placed, it is advisable to cut down upon the site of the fracture, remove the obstacle, and fasten the fragments together. So long as one bone is broken in the forearm the other may be relied on to act as a more or less efficient splint. There is but one position in which any of these fractures can be dressed with safety, that is _midway between pronation and supination_, _i. e._, with the thumb pointing toward the patient’s face. Splints used for this purpose should always be wider than the forearm itself, lest by pressure the ends be forced toward the other bone. Some hold that by gentle pressure along the line between the bones, as by a narrow pad or splint, the muscles may be made to press the injured bone away from the other; nevertheless only moderate pressure can be tolerated for this uncertain purpose. It has been generally customary to use two light wooden splints, one along the palmar, the other along the dorsal surface of the forearm, padding them properly and securing them in position by strips of adhesive plaster and suitable bandages. The same plaster-molded splints mentioned above can, however, be made just as effective for this purpose, if properly applied.

When either bone is broken near the wrist, and especially when both are broken, we have to combat the tendency of the pronator quadratus, which tends to pull the lower fragments together.

The _styloid_ process is occasionally detached, as in violent sprains, or broken off in connection with other injuries. Inasmuch as it carries the upper end of the internal lateral ligament its detachment can be quickly recognized by the abnormal freedom of motion which such an injury would permit.

Obliteration of the interosseous space in a fracture of the forearm.]

FRACTURES OF THE RADIUS.

The radius vies in frequency of fracture with the clavicle. The _head_ is seldom broken, its fracture being most likely when the shaft is driven against the humerus by falls upon the open hand. The _neck_ is more frequently broken in children than in adults. These fractures have sometimes to be determined by a process of exclusion or by the use of the _x_-rays. In muscular forearms they lie so deeply that it is not always possible to recognize them. Ordinarily, however, if the head of the bone can be found to remain stationary while the rest of the bone is being rotated, and if, at the same time, crepitus be felt, the matter may be regarded as settled. So far as the _shaft_ of the radius is concerned the remarks made above regarding the ulna mostly hold true for its fellow-bone. When the neck of the bone is broken the shaft will be pulled upward by the biceps tendon, while when the shaft is broken below its insertion the upper fragment is displaced by it. In either of these cases, then, the forearm should be dressed at a right angle with the arm in order to relax the muscle. The supinator brevis and the pronator radii teres should also not be neglected, for the former will tend to rotate and the latter to more or less displace the upper portion of a shaft broken high up. With a fracture near the upper end, in a powerfully muscular arm, diagnosis is not always easy. Fractures in the lower portion of the shaft are to be treated like those of the ulna. But those high up should be dressed with the elbow at a right angle and the forearm supinated. A plaster-of-Paris molded splint here can be adapted to the needs of every individual case if the surgeon will give minute care _at the time of its hardening_ to placing the parts just as he desires them to remain.

FRACTURES OF BOTH BONES OF THE FOREARM.

These are not uncommon, though much less frequent than injuries to either bone alone. They may occur at the same level or be quite widely separated. The loss of function is complete in these instances, while deformity will depend largely upon whether the fractures lie near together or not. It is of the greatest importance to remember, in these cases, that the mass of muscles around the upper fragments tends to crowd them together, while the lower fragments are brought together especially by the pronator quadratus. Everything then conspires to convergence of the four fragments, a tendency which it is sometimes difficult to combat. Every large museum contains specimens showing a common callus, in which all four bone ends are involved, and illustrating the permanent loss of rotation that ensues. This is to be combated, not alone by rest, which tends to limit callus formation, but by _position with the arm midway between pronation and supination_, in which the bones are naturally farthest separated, and by _splints_ applied with such gentle pressure as may hold the bones apart. This pressure should be applied between the dorsal and palmar surfaces, while the lateral aspects of the forearm should be kept absolutely free from it (Figs. 300 and 301).

Fracture of both bones near lower extremity. (Lejars.)]

It is a serious matter to dress any of these injuries with moistened pasteboard, or other material which does not take its desired shape and strength promptly, for no matter how carefully the desired position may be enforced at first the very nature of a material which remains too long plastic will permit the loss of all that should be maintained. The writer has seen malpractice suits instituted and men forced out of the State by inattention to this precaution.

FRACTURE OF THE LOWER END OF THE RADIUS; COLLES’ FRACTURE.

This is perhaps one of the commonest fractures in the body, occurring at all ages; when seen in growing children it is to be regarded as an epiphyseal separation rather than as a distinct fracture. It derives its name from the fact that until Colles, a Dublin surgeon, over one hundred years ago, described this injury as a fracture it had been always regarded as a peculiar dislocation at the wrist. It is produced by falls upon the hand in the hyperextended position, the force being usually transmitted through the carpus to the radial end. The name is usually limited to those fractures which occur within one and a quarter inches of the articular surface (Fig. 303). Here the structure of the bone is cancellous and impaction may easily occur, this being a decided feature in many of these accidents, and making replacement more difficult. The deformity which results from the fracture is characteristic and more or less uniform. This is called the “silver-fork appearance,” the lower fragment being so displaced, and usually more or less tilted, as to raise the tendons and the structures on the back of the wrist; at the same time it is usually drawn toward the radial side. The more the fragment is impacted or driven into the shaft of the bone the less easily is crepitus elicited.

The fracture is more common than is supposed, and there is no doubt but that many alleged sprains of the wrist illustrate cracks in the bone without displacement, which, nevertheless, are slow to heal and are sometimes followed by thickening and impairment of function. (See Plate XL.)

Along with the radial fracture separation of the _styloid process_ of the ulna may also occur, or, as Moore has shown, the process itself may perforate the internal lateral ligament so as to protrude through the skin; and the surgeon has occasionally to withdraw the styloid from the ligament which has been impaled upon it. The radio-ulnar ligament is also frequently injured, and this permits the ulna to become more prominent than normal. If the styloid has perforated the skin it lends a compound feature to the case. The interarticular fibrocartilage may also be displaced.

=Treatment.=--The secret of obtaining a good result and the explanation for failures lie in the completeness or incompleteness of the reduction of the fragment. If the latter be _absolutely and accurately replaced_ it makes but little difference what dressing is applied. On the other hand any fragment not completely restored will lead to subsequent deformity and impairment of function. _Successful reduction, then, is the keynote to success_, and should be accomplished at any reasonable cost. Sometimes it is not difficult, and then no anesthetic is required; sometimes it is extremely difficult, and the operator has to exert all the strength he has in his arms, aided by profound anesthesia. Moderate cases can usually be dealt with successfully under nitrous oxide gas. The surgeon grasps the hand as if to shake hands, _i. e._, with his corresponding hand, the elbow being firmly held by an assistant. Traction is then made upon the hand to which the fragment is affixed, while with his other hand the operator makes such pressure, rotation, or coaxing manipulation with his thumb and fingers as may assist in restoring the fragment to its place. With whatever other effort may be made traction should be combined. Forcible swaying movements, combined with hyperextension, may be necessary to dislodge an impacted fragment. Any degree of force is preferable to failure in this respect. Perfect reduction is the key of success; without it, no dressing is efficient; with it, almost anything will suffice.

Comminuted but not compound fracture of wrist. (Beatson.)]

Reduction once accomplished it is usually an easy matter to hold the arm in position. The writer prefers above all other means a molded plaster-of-Paris splint, which should extend from the line of the knuckles upon the palmar surface well up toward the elbow. It should be fitted neatly to the hand and forearm, bandaged comfortably upon it, while as it solidifies the surgeon should hold the hand slightly flexed to the ulnar side as well as anteriorly. When the splint is hardened and bandaged a simple sling will suffice. The hand should be dressed with the thumb pointing toward the face, while upon the back of the wrist an ice-bag can be applied. Ecchymosis is sometimes extreme; I have seen it extend even to the shoulder after an apparently simple break (Figs. 304 and 305).

Skiagram of a Fracture of the Lower End of the Radius. (Wharton.)]

I have not described other splints for dressings, at this point, for two reasons: the dressing given above is ample and sufficient for all cases, and, aside from it, the number of splints and methods devised is so large as to be confusing. It is much better to know one method well than to have a slight working acquaintance with several.

Colles’ fracture. (Anger.)]

FIG. 305

Deformity from faulty union following fracture of wrist. Buffalo Clinic. (Skiagrams by Dr. Plummer.)]

While Colles’ fracture is far more frequent than all other fractures about the wrist, it is possible to have less-known forms with different displacements; thus a fracture the reverse of Colles’ has been described by Barton and by R. W. Smith, being occasionally produced by falls upon the back of the hand instead of upon the palmar surface. Figs. 306 and 307, from photographs given me by Dr. Beatson, of Glasgow, illustrate both the clinical picture and the actual condition of the bones. Of all these fractures it may be said that accurate reposition, as in the case of Colles’ fracture, is the key to success. Once the fragments are reduced the same plaster-of-Paris molded splints will answer for these as for the others.

A Barton or Smith fracture at wrist. (Beatson.)]

Smith’s fracture; reverse of Colles’. (Beatson.) (Skiagram of case represented in Fig. 306.)]

BENNETT’S FRACTURE.

When considerable force is applied to the distal end of the first metacarpal, as in striking with the clenched fist, or, as in a fall upon the outstretched thumb, the first metacarpal is often fractured transversely at its neck or longitudinally, its interior basal projection being broken off, both injuries being often associated. This is a condition lately proved by Russ, of San Francisco, to be more common than has been generally supposed. It was first described by Bennett, of Dublin, in 1885, and is known as Bennett’s fracture of the thumb. Its peculiar features can be best seen in a radiograph. It produces much pain and swelling of the hand, with tenderness, especially at the base of the bone involved, _i. e._, at the root of the thumb. There may be more or less displacement of fragments. The injured thumb should be treated by traction and with such coaptation splints as may be extemporized or prepared for the purpose, in the position of abduction. If accurate coaptation and sufficient traction be made to overcome both deformity and muscle spasm the result obtained will be satisfactory. Otherwise more or less loss of function and local tenderness may long persist.

Skiagram of Fracture of the Proximal Phalanx of the Ring Finger. (Wharton.)]

FRACTURES OF THE WRIST AND HAND.

Fractures of the carpal bones seldom occur, except when the parts have been crushed. The _scaphoid_ is, however, broken much more often, and doubtless many cases of so-called severe sprain include this injury. The use of the _x_-rays has done more to teach the relative frequency of carpal fractures than was ever previously appreciated. The scaphoid ossifies by two centres, which do not appear until the eighth year. When the bone has been thus cracked the usual signs of sprain are present, which subside and leave a tender wrist and hand whose fingers can be normally moved, but whose wrist movements are reduced one-half, while attempts at motion beyond these limits produce great muscle spasm and pain. Codman and Chase[40] have shown that the sheaths of the radial extensor tendons are in close relation to the periosteum of the bone at this point, as well as to that of the radius, so that by injury here blood may escape into the sheath without appearing at other parts; the result being a tense, fluctuating, triangular swelling over the radial half of the wrist, the blood being effused so deeply as not to discolor, or at least not at first. They regard the presence of such an engorged bursa as diagnostic of fracture either of the radius or the scaphoid.

[40] Annals of Surgery, March, 1905.

While carpal fractures call ordinarily for treatment by absolute rest, Codman and Chase have advised removal of any loose fragment, especially of the scaphoid, by incision along the back of the wrist just to the inner side of the long radial extensor. The annular ligament is to be divided between it and the long extensors of the fingers, and without opening tendon sheaths; inasmuch as this ligament does not retract when divided its borders must be held apart. In this way the joint may be completely exposed over the proximal half of the scaphoid. The line of fracture being made out, a blunt hook is introduced into the fissure and the fragment elevated, loosened by a tenotome, and removed, its removal seeming nowise to interfere with the function of the whole bone or the usefulness of the wrist.

The _metacarpal bones_ are frequently broken, usually as the result of violence, the distal portions suffering more than the proximal. The diagnosis is best made with the fingers closed, when any lack of symmetry in the row of knuckles may be seen or any protrusion of a fragment noted. Here the _x_-rays are useful. Such injury should be treated by placing the hand upon a palmar splint extending well up the forearm and maintaining rest by suitable pressure, with or without traction upon the finger of the bone involved. For this purpose adhesive plaster may be passed up and down the finger and attached to an elastic band which is fixed to the end of the splint.

The same is true of fractures of the _phalanges_, which are often made compound by the injury. Here the danger is not so much to the bone as to the tendon sheaths or thecæ, along which infection may easily spread. Widespread and prolonged suppuration might disable a hand thus injured unless properly and promptly dressed. Ordinarily adjoining fingers can be utilized for splints, and if the outstretched hand be fastened upon a palmar splint and the injured finger kept in position by its neighbors a good result can generally be obtained. Occasionally distinct splints for one or more fingers are required, and occasionally also the suggestion made above with regard to traction may need to be enforced.

FRACTURES OF THE PELVIS.

Fracture of the pelvis may be serious not only in and of itself but because of frequently accompanying injuries to the various pelvic viscera. Save in the possible separations that may occur during parturition it is always the result of direct violence. Such injuries are usually divided into fractures of the _pelvic girdle_ and those of the more exposed prominences, such as the _iliac crest_, the _ischiac tuberosity_, the _coccyx_, etc. Lines of fracture may run at any point, although it is at the synchondrosis that the pelvis is usually broken loose from the sacrum. As in the skull and the lower jaw double fractures or even comminutions may occur. The same considerations concerning the transmission of serious violence may account for some of the vagaries seen in these cases. The _sacrum_ is usually broken as the result of great violence. The pelvic girdle is perhaps weakest opposite the joints and in the neighborhood of the pubis. Here there may be a separation of the symphysis, but the break usually occurs a little to one side of the middle line. In rare instances the head of the femur has been forced through the acetabulum (Fig. 308).

In a general way fractures of the pelvic girdle can be recognized not merely by local evidences of injury and shock, but by the resulting more or less complete loss of function; patients will be disabled in proportion to the violence and extent of the injury. The more unilateral the symptoms the easier it is to localize the site of the injury. Mobility can often be detected upon examination, sometimes crepitus. This is essentially true of fractures of the pubis. Occasionally combined manipulation, with a finger in the rectum or vagina, will permit more accurate localization of the injury. When the crest of the pelvis is fractured, or any of the parts to which the abdominal muscles are inserted, then the patient will be still further disabled in movements of the lower part of the body, while by palpation the fracture is sometimes easily determined.

Not the least serious features of these injuries are those which pertain to the viscera. These include not only the ordinary results of abdominal contusions which may produce all sorts of harm, for example, ruptures of the kidneys, spleen, or liver, but also more localized lesions, such as ruptures of the rectum, bladder, or urethra, or even the pelvic connective tissue. If the urinary passages be torn there is always opportunity for urinary infiltration and infection. The same is true of the rectum so far as possibility of infection is concerned. Therefore one of the earliest maneuvers in dealing with such a case should be the passage of a catheter, to determine if the urine be bloody or the urethra obstructed. In such a case, in the male at least, it will usually be wise to make a perineal section and to open widely and then drain the bladder. In not a few of these instances the laceration takes place internally, and a pelvic crushing injury, which is followed by collapse and abdominal rigidity, without satisfactory explanation as above, should be _promptly explored_ by abdominal section, the danger of doing it being considerably less than the risk of leaving it undone.

Fracture of pelvis. (Mudd.)]

Great deformity after multiple fracture of femur, with synostosis. (From the Buffalo Museum.)]

Some of these fractures are conspicuously _compound_, and the treatment for the external wound will permit of more careful exploration of the bone injury, as well perhaps as the insertion of wire sutures or other means of fixation.

Fig. 309 illustrates a serious complication that ensued in one case after multiple fractures of the pelvis and hip, with synostosis at the hip, as well as extensive deformity following fracture of the shaft of the femur.